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*W*CSTATE ID NUMBER 000000421950, <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AOENC ) q.r� PUBLIC AGENCY ONLY <br /> ROBERT T. BAKEWELL 0)((Cf �y. Q.014/C(< SUSAA) 134KC-045LL- ( ) 01 FED ( ) 02 STATE f 1 03 LOCAL <br /> STREET ADDPESS CITYSTATE ZIP <br /> 26989 E. HWY 4 (( FARMINGTON CA 95230 <br /> II FACILITY I <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 26989 E. HWY 4 <br /> CITY COUNTY ZIP <br /> FARMINGTON SAN JOAQUIN 95230 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 152 95230 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-886-5407 ( ) 01 GASOLINE STATION (X) 02 OTHER RESIDENCE <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 1 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> BAKEW LL,_RO6t T- 209-886-5407quj2f <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 400 GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X).02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( 1 INCHES ( 1 CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( 1 02 SINGLE WALLED ( ] 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS f l 04 POLYVINYL CHLORIDE l l 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (30/18/85) PAGE 1 <br /> Kam <br />